Maintenance treatment with antipsychotic drugs for schizophrenia

Antipsychotic drugs are the mainstay of treatment of schizophrenia, not only in the event of acute episodes, but also in the long-term perspective. While people might want to stop their treatment at some stage, recurrences of psychotic symptoms are known to occur after treatment discontinuation. Relapses can lead to risk of harm, loss of autonomy and substantial distress for individuals and their families.

The current report presents the update version of a systematic review previously published in 2012, and is based on 75 randomised controlled trials (RCTs) published over a long period since the 1950s and including more than 9000 participants. The effects of all antipsychotic drugs are here compared to those of placebo - namely drug discontinuation - for maintenance treatment, that is prevention of relapses. The aim is to explore the benefits and risks of each of the two options.

The results of this review show very consistently that antipsychotic drugs effectively reduce relapses and need for hospitalisation. Indeed, in case of treatment discontinuation, the risk of relapse at one year is almost three times higher. Antipsychotic drugs appear to have a positive effect on the ability to engage in activities and relationships, and on the possibility to fulfil remission from symptoms, although less evidence is available in this regard. Though based again on a lower number of reports, people continuing their treatment tend to experience higher satisfaction with their life, which confirms the negative consequences on well-being of being at higher risk for recurrence. Conversely, antipsychotic drugs are, as a group, associated with a number of side effects such as movement disorders, weight gain and sedation. However, this review allows more understanding of the fact that stopping treatment is far more harmful than thoughtfully maintaining it.

Unfortunately, studies included in this review do generally last up to one year, and this makes difficult to clarify the longer-term effect of these drugs. It is however true that the longer the study the more likely that other factors - e.g. environmental – may accumulate and complicate the interpretation of results. Most of all, this review supports the advantages of antipsychotic drugs among many different types of participants. The best strategy would be therefore to continue treatment with antipsychotics, eventually discussing and adapting it if any adverse effect occurs.

Authors' conclusions: 

For people with schizophrenia, the evidence suggests that maintenance on antipsychotic drugs prevents relapse to a much greater extent than placebo for approximately up to two years of follow-up. This effect must be weighed against the adverse effects of antipsychotic drugs. Future studies should better clarify the long-term morbidity and mortality associated with these drugs.

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